Nebraska Elemental Formula Reimbursement Program

 
 
 
 
 
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What you need to know

​​NEW PHONE NUMBER: (402) 471-0158
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According to Nebraska Revised Statute 68-158, Nebraska residents with certain conditions that require medically necessary amino acid-based elemental formulas may receive reimbursement of up to fifty percent (50%) of out-of-pocket expenses for these formulas. A maximum reimbursement of $12,000 is available in the twelve month period referenced below.
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Eligibility Requirements:

  • Require an amino acid-based elemental formula for the treatment of Immunoglobulin E and non-Immunoglobulin E mediated allergies to multiple food proteins, food-protein-induced enterocolitis syndrome, eosinophilic disorders, or impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract;
  • Have out-of-pocket expenses for this formula not covered by private insurance, Medicaid or other government insurance, WIC, or charitable grants;
  • Reside in the State of Nebraska;
  • Be a US Citizen or be legally present in the United States; and
  • Provide the applicant's Social Security number (or the parent's/guardian's if applicant is a minor) necessary to process the reimbursement.
  • All forms and supporting documents required to determine eligibility must be properly completed and approved in order to qualify.​

Need to Know:

  • Reimbursement for Amino Acid-based formula is on a first-come, first-served basis until funds available are exhausted in a fiscal year.
  • The 12 month period starts July 1st to June 30th. Applicants are eligible for up to $12,000 within the 12 month period as long as funding allows.
  • If applicable, applicants must provide proof that insurance will not cover the formula. All forms of documentation must show the name of the applicant.  One of the following can be used as proof of insurance denial:
    • Denial letter from the insurance company
    • Your insurance policy with a copy of your insurance card
    • Denied insurance claim
  • Completed applications will be processed in the order in which they are received. 
  • Receipts dated on or after the Physician's Statement signature date are eligible for reimbursement. Any receipt prior to this date will not be reimbursed. Any receipt more than 6 months old will not be reimbursed, regardless of Physician's Statement.
  • Participants will need to send updated Physician's Statements and insurance denials on a yearly basis to continue the program.
  • Communication to approve an application or request more information should be received within 10 business days of submitting a complete application.  If the applicant has not received communication, please contact DHHS. It is the applicant's responsibility to ensure that DHHS has received the submitted application.
  • Communication for this program is through email. Please make sure the email address that is provided on the application is current and legible.​

How to Apply:

          Nebraska Elemental Formula Reimbursement Program
          Lifespan Health Services Unit
          Nebraska Department of Health and Human Services
          P.O. Box 95026
          Lincoln, Nebraska 68509-5026

  • After the submitted application is reviewed, you will be notified through email if your application is approved or more information is needed. 

Submitting Reimbursements:

  • Must have an approved application on file.
  • Eligible receipts must be submitted with a completed Reimbursement Claim Form and include the following information:
    • Date of transaction
    • Itemized list of purchases
    • Proof of payment
    • Complete Order Summary
    • Proof of delivery if the item was purchased online
  • Limit submission of receipts to 2-5 at a time.
  • Receipts must be legible.



Nebraska Elemental Formula Reimbursement Program
Department of Health & Human Services
  Email Address
Mailing Address
P.O. Box 95026, Lincoln, Nebraska 68509-5026

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